Stable angina

Stable angina. It is a chest pain or discomfort that often occurs with activity or stress . The angina is a discomfort in the chest caused by poor circulation through the blood vessels (coronary vessels) of the muscle heart (myocardium).

By definition, that angina of effort in which there have been no changes in its presentation in the last month, and implies the unforeseeable appearance of complications imminently or unfavorable evolution in the immediate future.

Summary

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  • 1 Concept
  • 2 Most typical location
  • 3 Classification
  • 4 Pathophysiology
  • 5 Symptoms
  • 6 Possible complications
  • 7 Bibliography
  • 8 Source

Concept

Ischemic heart disease encompasses a range of entities that we can basically divide into chronic coronary artery disease (stable angina) and acute coronary syndromes (unstable angina, acute myocardial infarction, and sudden death).

Angina is the most characteristic symptom of ischemic heart disease, being defined by the Spanish Society of Cardiology as: “pain, oppression or discomfort, generally thoracic, attributable to transient myocardial ischemia”.

Most typical location

It is the retrosternal (it can be seen in any area between the epigastrium and the jaws, including the arms), and irradiation from its initial location to other areas is frequent.

Generally the triggering factor is physical effort (we can find others such as cold or stress) and the anginal threshold, in most cases, is fixed.

The typical angina episodes usually last a few minutes (rarely more than twenty or less than one), disappearing with rest or after using sublingual nitroglycerin.

It is important to keep in mind that the concept of angina is clinical and, therefore, its diagnosis is also. Angina is not synonymous with ischemia (there may be ischemia without angina: silent ischemia) or coronary obstruction (angina may occur without obvious angiographic lesions: vasospasm, microvascular disease, aortic stenosis or in hypertrophic cardiomyopathy; on the other hand, there may be lesions significant coronary arteries without angina: in case a sufficient collateral network has developed or if there has been previous necrosis of the irrigated area, for example.)

Classification

To assess the severity of stable angina, we used the Canadian Cardiovascular Society classification , which recognizes four degrees:

  • Grade I:Ordinary physical activity, such as walking or climbing stairs, does not produce angina. Angina results from strenuous, quick, or prolonged exercise.
  • Grade II: slight limitation of ordinary activity. Angina appears in the following circumstances: walking or climbing stairs quickly, climbing hills, walking or climbing stairs after meals, in cold or windy conditions, under emotional stress or only during the first hours of the day. Under normal circumstances and at a normal pace, the patient is able to walk more than two blocks on the plain and climb more than one floor of stairs.
  • Grade III: manifest limitation of ordinary physical activity. Angina can appear when walking one or two blocks or climbing a floor of stairs.
  • Grade IV: the patient is unable to carry out any type of physical activity without angina. Resting angina may occasionally appear.

New York Heart Association (NYHA) graduation is used in some references to functional class , although this classification was developed specifically for heart failure.

It is also important to keep in mind the relativity of these graduations and their interpretation, since, for example, the ordinary physical activity that a young patient can carry out is not the same as an elderly one.

Pathophysiology

The pathophysiological substrate for stable angina is a coronary obstruction determined by an atheroma plaque, the nucleus of which grows slowly and reduces the caliber of the vessel significantly, in such a way that at baseline or below a certain level of requirements It is capable of maintaining an adequate myocardial supply, but when this threshold is exceeded, it is unable to meet the needs that are currently being generated, with myocardial ischemia appearing and, as a consequence, alteration in contractile function, changes in the electrocardiogram and angina as a manifestation. clinic.

The situation is normalized when the needs fall below that threshold again and the basal flow, although compromised, is able to maintain an adequate contribution.

It is, therefore, a situation of light and transient ischemia due to increased myocardial oxygen needs in the presence of a coronary flow limiting lesion.

To this plate of fixed atheroma or stenosis, a dynamic obstruction can sometimes be added due to coronary vasospasm, which determines small variations in the anginal threshold and even some sporadic and brief episode at rest.

It is important to understand the difference between the pathophysiology of stable angina, which we have seen previously, and that of acute coronary syndromes, where the main event is the complication of an atherosclerotic plaque (which on the other hand is not usually severely obstructive) with a fissure. -plate rupture and superimposed thrombosis, which determines a sudden and critical interruption of the coronary flow that causes a very intense ischemia, so that if the situation is not restored and lasts long enough, it leads to necrosis of the irrigated myocardium for the glass affection.

The concept of stability is, therefore, a clinical, histopathological and also prognostic concept, since the fact that there have been no recent clinical changes implies that, most probably, there have also been no changes at the histological level, and therefore It is not logical to think that they will occur in the immediate future.

Thus, the diagnostic-therapeutic management of these patients can be carried out without the urgency that other processes require, such as unstable angina, whose imminent future is unknown.

Symptoms

The symptoms of stable angina are often predictable. This means that the same amount of exercise or activity can cause angina to develop. Your angina should improve or disappear when you stop or decrease exercise.

The most common symptom is chest pain that occurs behind the breastbone or slightly to the left. Stable angina pain usually starts slowly and gets worse in the next few minutes before it goes away.

Pain can be felt as stiffness, tightness, oppressive or constricting pain, and can radiate to:

  • The arm (usually the left).
  • The back .
  • The jaw .
  • The neck .
  • The shoulder .

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